**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure two (2) of eight (8) sampled (Residents #77 and #88) and one not in the selected sample (Resident #59) were treated with respect and dignity. Observations revealed Certified Nurse Aide (CNA) #1 stood over Residents #77, #88 and #59 while assisting with feeding snacks in commons area. The findings include: Review of the facility policy, Quality of Life, Dignity dated 09/01/18 revealed, each resident will be cared for in the manner in which promotes and enhances quality of life, dignity, respect and individuality. Resident shall be treated with dignity and respect at all times. 1. Record review revealed the facility admitted Resident #59 on 10/30/13 with diagnoses which included Dementia with Behavioral Disturbance, Peripheral Vascular Disease, Psychotic Disorder with Delusions, and Major Depressive Disorder. Review of the Annual Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #59's was unable to complete the Brief Interview of Mental Status (BIMS) due to severe cognitive impairment which indicated the resident was mot interviewable. Observation on 08/20/19 at 9:48 AM revealed CNA #1 was standing at Resident #59's side and was feeding the resident yogurt and pudding while the resident sat in wheelchair. Observation on 08/21/19 at 10:11 AM revealed CNA #1 was giving Resident #59 a snack of fruit juice. The CNA hovered over resident and did not sit beside resident or bend down to eye level. 2. Record review revealed the facility admitted Resident #77 on 04/02/18 with diagnoses which included Dementia with Behavioral Disturbance, Peripheral Vascular Disease, Delusional Disorders and Generalized Anxiety Disorder. Review of the Quarterly MDS assessment dated [DATE] revealed the facility did not attempt to complete the BIMS due to the resident being rarely/never understood. Observation on 08/21/19 at 10:11 AM revealed CNA #1 was assisting Resident #77 to drink a snack of fruit juice while standing at his/her side. 3. Record review revealed the facility admitted Resident #88 on 06/28/18 with diagnoses which included Alzheimer's Disease, Vascular Dementia with Behavioral Disturbance, Anxiety Disorder, and Cerebral Infarction due to Embolism of Cerebral Artery. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #88 was unable to complete the Brief Interview of Mental Status (BIMS) due to severe cognitive impairment which indicated the resident was mot interviewable. Observation on 08/20/19 at 10:27 AM, revealed CNA #1 was standing at Resident #88's side while feeding him/her a snack. Interview with CNA #1 on 08/21/19 at 10:46 revealed, If we feed them, we are suppose to sit down beside them. She stated she did not think giving snacks was actually feeding the resident. Interview with the Unit Manager on 08/21/19 at 10:57 AM revealed she expected staff to sit at a resident's side to give snacks or feed resident. Interview with Director of Nursing (DON) on 08/21/19 at 12:58 PM revealed she expected all staff feeding residents to be at eye level when feeding or giving fluids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles to include the expiration date when applicable. Observations of four (4) of seven (7) medication carts revealed two (2) vials of eye drops, one (1) insulin pen, and (1) bottle of Lactulose liquid not dated when opened. Additionally, observation of two (2) of four (4) medication storage rooms revealed (1) bottle of Novolin R insulin was opened [DATE] and had gone past the twenty-eight (28) days of recommended use. The findings include: Review of the facility policy titled, Vials and Ampules of Injectable Medications, not dated, revealed the date opened and the initials of the first person to use the vial were to be recorded on multidose vials on the vial label or an accessory label affixed for that purpose. Observation of four (4) of seven (7) medication carts on [DATE] at 9:55 AM, revealed one (1) insulin pen, two (2) bottles of eye drops and one (1) bottle of Lactulose liquid not dated when opened. Additional observation on [DATE] at 10:15 AM of two (2) of four (4) medication storage rooms, revealed one (1) vial of insulin opened on [DATE] and was in use past the twenty-eight (28) day use cycle (expired). Interviews on [DATE] with Licensed Practical Nurse (LPN) #1 at 10:08 AM , Registered Nurse (RN) #2 at 10:17 AM, and RN #1 at 10:55 AM revealed any multidose vial of medication should be dated when opened by whomever opened the medication initially. Interview with the Director of Nursing (DON), on [DATE] at 12:55 PM, revealed she expected multidose vials to be dated when opened by the nurse that opened the medication.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (1) resident (Unsampled Resident #39) not in the selected sampled of eighteen (18) . Observation of a facility medication pass on 05/23/18 revealed a licensed staff crushed a Do Not Crush medication. The findings include: Review of facility policy titled, Medication Administration-General Guidelines, last revised 12/18/12, revealed medications are administered as prescribed in accordance with good nursing principles and practices. Further review of this policy revealed, if it is safe to do so, medications tablets may be crushed, but long acting or enteric coated dosage forms should generally not be crushed. Record review revealed the facility admitted Unsampled Resident #39 on 09/08/16 with diagnoses which included Angina Pectoris. Review of Unsampled Resident #39's Quarterly Minimum Data Set (MDS) assessment, dated 03/27/18, revealed the facility assessed this resident's cognition as moderately impaired with a Brief interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Review of Unsampled Resident #39's Physician's Order, dated 04/16/18, revealed to administer Imdur Tablet Extended Release 24 hour 30 milligrams (mg) to be given by mouth one time daily. Further review of these orders, revealed directions to Do Not Crush this medication. Review of Unsampled Resident #39's Medication Administration Record (MAR), dated May 2018, revealed Imdur Tablet Extended Release 24 hour 30 mg one time daily by mouth. Do Not Crush. Observation of Licensed Practical Nurse (LPN) #2 performing a Medication Pass on 05/23/18 at 9:03 AM, revealed LPN #2 crushed Unsampled Resident #39's Imdur Extended Release medication (used to to prevent Angina/chest pain). Interview with LPN #2 on 05/23/18 at 9:08 AM, revealed she was expected to not crush extended release medications that are Do Not Crush medications. She stated she normally does not crush Unsampled Resident #39's Imdur extended release medication and was not sure why she did. Interview with Unit Manager #1 on 05/23/18 at 10:16 AM, revealed she expected all licensed staff and med techs to follow physician's orders and medication guidelines. She stated she would expect staff to not crush Do Not Crush medications. Interview with Advanced Practice Registered Nurse (APRN) #1 on 05/23/18 at 9:27 AM, revealed she would expect the staff to ensure they are not crushing medications that are extended release. She stated by crushing extended release medications it could cause the medication's desired effect to not be what it was intended. She stated Unsampled Resident #39 has been stable, however based on the medication that was crushed and given to him/her they would need to monitor him/her and take blood pressure readings throughout the day. Interview with Director of Nursing (DON) on 05/23/18 at 10:08 AM, revealed she expected all staff who pass medications to follow the physicians orders. She stated she expected staff not to crush extended release medications or do not crush meds. She stated it is not acceptable for a nurse or med tech to crush Do Not Crush medications and she would expect them to know not to crush Extended Release Medications.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure appropriate and proper incontinent care was performed, related to glove changes and hand hygiene for one of eighteen (18) sampled residents (Resident #60#)and one unsampled resident (Unsampled Resident #69.) Observations revealed staff did not wash hands in between glove changes and after the handling of objects at the bedside. The findings included: Review of the facility's policy titled, Hand Washing/Hand Hygiene, dated 10/01/17, revealed the staff were to have washed their hands, or used an Alcohol Based Hand Rub, before performing any clean or aseptic procedure, after removing gloves and after or in-between contacts with objects such as equipment in the immediate vicinity of the resident. Review of the facility's infection control policy titled Your five moments for Hand Hygiene dated May 2009, revealed the following: Clean your hands immediately after an exposure to body fluids(and after glove removal), after touching a patient and his or her immediate surroundings when leaving, after touching any object or furniture in the patient's immediate surroundings, and when leaving-even without touching the resident. 1. Record review revealed the facility admitted Unsampled Resident #69 on 01/29/14, with diagnoses which included Alzheimer's Dementia, Diabetes Mellitus, Glaucoma and Chronic Renal Disease. Review of the annual Minimum Data Set (MDS) assessment, dated 04/26/18, revealed the facility assessed the resident as severely cognitively impaired, always incontinent of bowel and bladder and totally dependent on staff for all care needs. Review of Unsampled Resident #69's Comprehensive Care Plan for incontinence, dated 10/07/15, revealed the resident required disposable briefs for containment and dignity; staff were to have checked the resident every two hours and as needed, and completed incontinent care. Observation of incontinent care for Unsampled Resident #69 with Certified Nurse Aides (CNAs) #1 and #2 on 05/23/18 at 10:00 AM, revealed CNA #1 failed to wash her hands or use sanitizer on hands after changing gloves and prior to applying another pair of gloves. Additionally, CNA #1 picked up the trash can at bedside and handed it to CNA #2 and failed to wash hands or re-glove and continued to complete cleaning the resident's buttocks. CNA #1 stated she probably should have used the alcohol cleaner between glove changes and after grabbing the trash can. Interview with the RN #2 on 05/24/18 at 2:30 PM, revealed she observed staff frequently and watched them completing incontinent care and ensured their competency. She stated the staff received in-services, at least every three months and she was sure the CNAs were trained on following the infection control and hand washing procedures. Interview with the Unit Manager, Registered Nurse (RN) #1 on 05/24/18 at 7:45 AM, revealed she would have expected the CNA's to have changed their gloves and washed hands or used the sanitizer, in between glove changes, as gloves are very porous and open to infectious processes. Interview with the Director of Nursing (DON) on 05/24/18 at 2:35 PM, revealed she would have expected the staff to have followed their training and stated the staff just had a training about the CDC guidelines. Review of the facility's policy titled, Dress Code/Standard of Appearance dated last revised 09/14/17, revealed all employees will maintain standards of personal hygiene, safety and infection control principles at all times while on duty. Further review of this policy revealed hair should be clean, well groomed and styled in a manner that does not interfere with resident care or the performance of duties and long hair should be tied back or worn up. 2. Record review revealed the facility admitted Resident #60 on 11/20/15 with diagnoses which included Dementia without Behavioral Disturbance, Cerebral Ischemia, Dysphagia and Eating Disorder. Review of a Significant Change MDS assessment, dated 04/18/18 revealed the facility assessed Resident #60's cognition as severely impaired with a BIMS score of seven (7), indicating the resident is cognitively impaired. Review of this same MDS revealed section G110 for Activities of Daily Living showed the resident to be totally dependent on staff with two person assist for toileting, and Section H0400 for Bowel and Bladder revealed the resident has a urinary catheter and is always incontinent of stool. Review of Resident #60's Comprehensive Care Plan dated 10/04/17 revealed to check for incontinent episodes every two hours and as needed; and provide incontinent care after each incontinent episode. Observation of incontinent care for Resident #60 with CNA #3 and LPN #1 on 05/23/18 at 10:00 AM revealed LPN #1 cleansed Resident # 60 of stool, then proceeded to touch the call light, handles on closet door, items in closet, and the bath room door handle before taking gloves off and washing hands. Additionally, LPN #1's hair was long, below shoulder length, and her hair was observed hanging down and touching the pad on the bed and linens at times during care. Observation of incontinent care on 05/23/18 at 10:10 AM revealed the resident had another bowel movement and was cleansed of stool by CNA #3. CNA # 3 did not change gloves after doing incontinent care and touched the resident's blanket, sheet, clothing, and clean pillow case with the contaminated gloves. Interview with CNA #3 on 05/24/18 at 10:37 AM revealed she realized after the fact she should have changed gloves as it is an infection control issue to be touching the resident's clothing and items in the room with dirty gloves. She stated she and LPN # 1 had discussed that LPN # 1 (not available for interview) should have changed gloves as it is an infection control issue to be touching closet door handles, items in the closet, call light and bathroom door handle with dirty gloves. CNA #3 stated when she had mentioned this to LPN #1 yesterday, LPN #1 also realized she should have had her hair pulled back when doing resident care as her hair touched the bed pad. CNA #3 stated if hair is below shoulder length,it should be put up. Interview with the DON on 05/24/18 at 10:37 revealed she expected staff to change gloves and wash hands after doing incontinent care before touching other items such as the call light, linens, closet handles, items in the closet, bath room door handles, and clean pillow case. She stated she also expect the LPN to have her hair up out of the way and not touching the bed sheet or pad when doing care.

Based on observation, interview, record review and review of the facility policy, it was determined, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, related to the failure to ensure the kitchen can opener was clean, a box of powdered thickener was sealed and the scoop was not laying in the thickener, and a box of fish squares were sealed. Review of the Census and Condition, dated 05/22/18, revealed eighty-six (86) of eighty-eight (88) residents received their food from the kitchen. The findings include: Review of facility policy titled, Ice, last revised April 2006, revealed ice buckets, other containers and scoops shall be kept cleaned and shall be stored and handled in a sanitary manner. Review of facility policy titled, Shelf Life and Date Marking last revised August 2012, revealed single service articles used by the facility shall be stored in closed cartons or container that protect them from contamination. 1. Observation of the walk in freezer, on 5/22/18 at 11:06 AM, revealed a box of fish squares open to air and not sealed. 2. Observation of the dry storage room on 5/22/18 at 11:12 AM, revealed a box of thickener open to air with a styrofoam cup, that staff were using to scoop thickener with, laying in the thickener. 3. Review of the facility policy titled, Sanitation, last revised July 2012, revealed the food service area shall be maintained in a clean and sanitary manner. Further review of this policy, revealed all kitchens, kitchen areas and dining areas shall be kept clean and all utensils, counters, shelves and equipment shall be kept clean. Observation on 05/22/18 at 11:19 AM, revealed the kitchen can opener had a visible build up of black/brown material on the cutting edge and area surrounding the cutting edge. Interview with the Food Service Manager on 05/23/18 at 11:00 AM, revealed she always expects the kitchen to be sanitary. She stated she expects the can openers to be cleaned after each use and they should not have any build up on them. She revealed any powdered material they use such as thickener, sugar or flour is to be sealed in a container when not in use and no scoop left in the product. She stated she expects all food to be in a sealed container of sorts and not open to air when being stored in the refrigerator, freezer or dry storage. Interview with the Assistant Administrator on 05/24/18 at 09:46 AM, revealed she expected food to be stored, distributed and served in a sanitary manner.